Recently I posted this:
This seems too good to be true.
I'd like people to confirm that my eyes aren't square:
A reduced risk of death from 21 in 1000 person years (assuming - this isn't explicit in the trial write up - person years corresponds to years under 5) to 11 deaths per 1000 person years for under 5s, who are covered by a micro-health insurance programme in rural Burkina Faso that costs around $1/year.
This translates to 1 infant death averted in every 100 infant years covered by the programme?
So 1 infant death per $120 assuming admin expenses of $20?
This seems unbelievable.
Unbelievable that there's a potential opportunity that effective.
Unbelievable that $1/yr can provide effective health coverage.
If it does hold for Burkina - the question is whether it will hold for other contexts?
You can read the original study here
http://www.globalhealthaction.net/index.php/gha/article/view/27327
there is disappointingly little raw data in it, but the researchers seem to be from a half reputable medical school in Germany.
Interested in people's thoughts - bunk?
Ben Kuhn's comment answers it pretty clearly. My eyes were square.
The trial I subsequently found to contradict this was much more persuasive - this doesn't look that promising but it might be depending on the context.
This is an observational study, not a randomized trial. As such, there are likely to be uncontrolled confounders that bias the inferred effect high compared to the true effect.
Also, I was going to note that there's a lot of cross-country heterogeneity in these programs, but then I realized that the authors misread the Rwanda study they cite; they write that
but in fact it was a reduction of 3-14 percentage points, which is huge. Actually, it's so huge that I'm a little confused; baseline infant mortality was only 8.6 per cent before the health insurance program started! This makes the high end (14 percentage points, from their instrumental variables model) implausible as an estimate of the population effect, since that would require insurance-seeking to be highly correlated with infant mortality.
Anyway, that notwithstanding, I would still expect external validity to be limited, given that other studies have observed substantially different results.
Thanks Ben :) Looking for a better study - here's a something with an imperfect but not too bad on the surface RCT protocol - which found pretty much no effect between full healthcare coverage and no healthcare coverage in the context of Ghana.
Such a shame these important questions are littered with such bad work.
Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial